Management of arrhythmias during pregnancy

The 2023 HRS Expert Consensus Statement on the Management of Arrhythmias During Pregnancy, dedicated exclusively to gestational arrhythmias, is a notable milestone in the management of women with heart disease.1Joglar J.A. Kapa S. Saarel E.V. et al.2023 HRS expert consensus statement on the management of arrhythmias during pregnancy.Heart Rhythm. 2023; (May 19) (02246-4): S1547-S5271PubMed Google Scholar It is meant to be an instrumental tool for the complex care teams established for the management of pregnant women with heart disease. This document strengthens the importance of the cardio-obstetrics team, ideally composed of a maternal–fetal medicine subspecialist, an electrophysiologist and/or a cardiologist with expertise in arrhythmias during pregnancy, a pediatric electrophysiologist when fetal arrythmias are present, an anesthesiologist, and a neonatologist. A coordinated team approach has been shown to improve outcomes in all areas of medicine, and cardio-obstetric medicine is no exception. A lack of high-quality studies has been highlighted in areas of maternal arrhythmia management, the optimal treatment of fetal arrhythmias, and the impact of treatment on maternal physiology. Pregnant women have long been excluded from large trials of arrhythmia management, leading to limitations in our ability to extrapolate data from these trials to the pregnant population. Syncope is not uncommon during pregnancy, complicating about 1% of pregnancies, with the majority having a vagal etiology.2Chatur S. Islam S. Moore L.E. Sandhu R.K. Sheldon R.S. Kaul P. Incidence of syncope during pregnancy: temporal trends and outcomes.J Am Heart Assoc. 2019; 8e011608Crossref PubMed Scopus (15) Google Scholar Syncope secondary to an arrhythmia or structural heart disease is associated with higher risk of adverse fetal and maternal outcomes, such as premature birth and congenital abnormalities.3Silversides C.K. Grewal J. Mason J. et al.Pregnancy outcomes in women with heart disease: the CARPREG II study.J Am Coll Cardiol. 2018; 71: 2419-2430Crossref PubMed Scopus (293) Google Scholar Supine hypotensive syndrome is unique to pregnancy and is commonly overlooked in the assessment of gestational presyncope. The left lateral positioning of the pregnant patient increases cardiac output significantly compared with a flat supine position.4Higuchi H. Takagi S. Zhang K. Furui I. Ozaki M. Effect of lateral tilt angle on the volume of the abdominal aorta and inferior vena cava in pregnant and nonpregnant women determined by magnetic resonance imaging.Anesthesiology. 2015; 122: 286-293Crossref PubMed Scopus (88) Google Scholar Palpitations are a very common pregnancy-related complaint,5Shotan A. Ostrzega E. Mehra A. Johnson J.V. Elkayam U. Incidence of arrhythmias in normal pregnancy and relation to palpitations, dizziness, and syncope.Am J Cardiol. 1997; 79: 1061-1064Abstract Full Text Full Text PDF PubMed Scopus (182) Google Scholar and the most common arrhythmias are generally benign, including sinus arrhythmia or sinus tachycardia or isolated ectopy. Symptoms due to these arrhythmias generally tend to resolve after delivery. Arrhythmias during pregnancy are more prevalent in the patient with structural heart disease. The incidence of gestational arrhythmia, particularly atrial fibrillation (AF) and ventricular arrhythmia (VA), is increasing as maternal age is increasing, as are maternal cardiovascular comorbidities. Adverse fetal events, such as prematurity, occur more frequently in pregnant patients with antepartum arrhythmias, especially in those with an underlying maternal congenital or acquired heart disease.3Silversides C.K. Grewal J. Mason J. et al.Pregnancy outcomes in women with heart disease: the CARPREG II study.J Am Coll Cardiol. 2018; 71: 2419-2430Crossref PubMed Scopus (293) Google Scholar,6Pillutla P. Nguyen T. Markovic D. Canobbio M. Koos B.J. Aboulhosn J.A. Cardiovascular and neonatal outcomes in pregnant women with high-risk congenital heart disease.Am J Cardiol. 2016; 117: 1672-1677Abstract Full Text Full Text PDF PubMed Scopus (25) Google Scholar,7Silversides C.K. Harris L. Haberer K. Sermer M. Colman J.M. Siu S.C. Recurrence rates of arrhythmias during pregnancy in women with previous tachyarrhythmia and impact on fetal and neonatal outcomes.Am J Cardiol. 2006; 97: 1206-1212Abstract Full Text Full Text PDF PubMed Scopus (174) Google Scholar Hospital admissions for gestational arrhythmia are associated with greater in-hospital mortality as well as maternal and fetal complications. The identification of underlying structural heart disease is the first step in management planning, particularly as it pertains to VAs and thromboembolic risk in atrial arrhythmias. AF is becoming the most common newly diagnosed arrhythmia during pregnancy. Treatment strategy should be based on hemodynamic tolerance and the underlying substrate, as in nonpregnant patients. The well-established scoring systems for stroke risk in AF have not been validated for use in pregnancy, but they can be helpful in identifying women who may be at greater risk for cardioembolic events when traditional risk factors are present. Other indications for anticoagulation will be dictated by underlying structural heart disease. The management of anticoagulation in pregnancy has been well described, and the same principles apply to the patient with gestational AF.8Mehta L.S. Warnes C.A. Bradley E. et al.Cardiovascular considerations in caring for pregnant patients: a scientific statement from the American Heart Association.Circulation. 2020; 141: e884-e903Crossref PubMed Scopus (166) Google Scholar The overall approach to the treatment of gestational arrhythmias is similar to the approach in a nonpregnant patient, with modifications for fetal safety. This consensus document emphasizes that the care of the pregnant patient with hemodynamically significant arrhythmias takes precedence over fetal monitoring, as restoration of maternal hemodynamics is in the best interest of both mother and fetus. The established guidelines for acute management of arrhythmias,9Page R.L. Joglar J.A. Caldwell M.A. et al.2015 ACC/AHA/HRS guideline for the management of adult patients with supraventricular tachycardia: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society.Heart Rhythm. 2016; 13: e136-e221Abstract Full Text Full Text PDF PubMed Scopus (70) Google Scholar,10Al-Khatib S.M. Stevenson W.G. Ackerman M.J. et al.2017 AHA/ACC/HRS guideline for management of patients with ventricular arrhythmias and the prevention of sudden cardiac death: executive summary.Circulation. 2018; 138: e210-e271PubMed Google Scholar and indications for permanent pacing or implantation of a defibrillator in the nonpregnant patient,11Kusumoto F.M. Schoenfeld M.H. Barrett C. et al.2018 ACC/AHA/HRS guideline on the evaluation and management of patients with bradycardia and cardiac conduction delay: executive summary: a report of the American college of cardiology/American heart association task force on clinical practice guidelines, and the heart rhythm society.J Am Coll Cardiol. 2019; 74: 932-987Crossref PubMed Scopus (148) Google Scholar should be applied during gestation, with attention to the choice of drug treatment to avoid teratogenicity. There are certain conditions wherein pregnancy strongly influences outcomes. Maternal long QT syndrome is associated with a higher risk of postpartum cardiac events in women considered to be “low” risk. 12Seth R. Moss A.J. McNitt S. et al.Long QT syndrome and pregnancy.J Am Coll Cardiol. 2007; 49: 1092-1098Crossref PubMed Scopus (252) Google Scholar In this case, the protective capacity of beta-blockade, particularly in the first 9 months postpartum, cannot be overstated. The other is the management of maternal cardiac arrest. Resuscitation in pregnancy must be optimized by left lateral uterine displacement, avoiding breast tissue when positioning defibrillation pads, and, in later pregnancy, preparation for urgent resuscitative hysterotomy. There are limited data regarding antiarrhythmic therapy in pregnancy. A risk-to-benefit discussion should consider established arrhythmia treatment guidelines and the safety of drug use during pregnancy and lactation. Fetal arrhythmias present a unique challenge to caregivers given the potential risk fetal hydrops. Sustained fetal tachycardias usually are treated by transplacental administration of antiarrhythmic drugs, direct fetal administration, or delivery of the infant,13Donofrio M.T. Moon-Grady A.J. Hornberger L.K. et al.Diagnosis and treatment of fetal cardiac disease: a scientific statement from the American Heart Association.Circulation. 2014; 129: 2183-2242Crossref PubMed Scopus (783) Google Scholar if viability has been achieved. This consensus statement highlighted the safety and efficacy of zero fluoroscopy–guided ablation procedures.14Razminia M. Willoughby M.C. Demo H. et al.Fluoroless catheter ablation of cardiac arrhythmias: a 5-year experience.Pacing Clin Electrophysiol. 2017; 40: 425-433Crossref PubMed Scopus (87) Google Scholar Coordination with a cardio-obstetrics team should include planning urgent delivery, especially with high-risk interventions. The risk of caval compression also should be considered, especially for procedures requiring anatomic mapping systems in which any patient movement needs to be minimized. The method of delivery is dictated by obstetrical factors, and there is often no cardiovascular advantage to an operative delivery.15Ruys T.P.E. Roos-Hesselink J.W. Pijuan-Domènech A. et al.Is a planned caesarean section in women with cardiac disease beneficial?.Heart. 2015; 101: 530-536Crossref PubMed Scopus (106) Google Scholar Epidural analgesia may be encouraged, with limited evidence supporting this approach in arrhythmia prophylaxis.16Tanaka H. Kamiya C. Katsuragi S. Tanaka K. Yoshimatsu J. Ikeda T. Effect of epidural anesthesia in labor; pregnancy with cardiovascular disease.Taiwan J Obstet Gynecol. 2018; 57: 190-193Crossref PubMed Scopus (9) Google Scholar Telemetry monitoring is indicated for women with a history of cardiac arrest, severe systemic ventricular systolic dysfunction, poor functional class, high-grade VA, or pre-excited AF. The establishment of this international consensus document is an important milestone for the community dedicated to the care of pregnant patients with heart disease. It is a testament to the success of generations of cardiologists caring for women with heart disease that these women are now reaching childbearing age and achieving term pregnancies under their care. It is an acknowledgement of what has been achieved thus far and an important opportunity to examine gaps in knowledge in the emerging field of gestational arrhythmia management.

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